New Heart Warning for Diclofenac

People with heart problems have been advised against using one of the most commonly prescribed anti-inflammatory drugs. The European medicines watchdog issued a warning in July 2013 stating that diclofenac can significantly increase the risk of heart problems such as heart attack and stroke in those already at risk of these problems. Diclofenac is a Non-Steroidal Anti-inflammatory Drug (NSAID) used as an anti-inflammatory painkiller. Many Irish people take diclofenac for a range of conditions such as back pain, arthritis, gout and headaches. According to HSE statistics*, diclofenac is the 18^th most commonly prescribed drug overall by doctors in Ireland with 568,000 prescriptions issued for diclofenac issued on the medical card alone in 2010. Diclofenac has been the second most commonly prescribed painkiller after paracetamol and the most commonly prescribed anti-inflammatory painkiller.

The Irish Medical Board (IMB) is advising against taking diclofenac if you have heart problems. Brands of diclofenac available on prescription in Ireland include Diclac^® tablets, Difene^® Capsules, Voltarol^® tablets and Catoflam^® tablets.

The IMB are advising doctors not to prescribe diclofenac for patients with a history of heart and circulation problems including heart failure, ischaemic heart disease (eg. Angina, previous heart attack), stoke and arterial thrombosis (eg. blood clots). People who are smokers, are diabetic, have high blood pressure or have high cholesterol should also use diclofenac in caution (even if they do not currently have heart problems) as these conditions increase your risk of heart disease and diclofenac further increases this risk. Research published in 2011 found that patients taking diclofenac were found to have a 40% increased risk of heart problems such as heart attack or stroke compared to those who were not using the drug. However, for most people; diclofenac only causes a slight increase in risk of heart problems

The warning covers diclofenac administered rectally (eg Difene^® suppositories) as well as oral versions mentioned above. The warning does not include topical versions of diclofenac such as creams and gels. Thus topical versions such as Difene^® Gel, Voltarol^® Gel or Difene^® Gel are still considered safe for cardiac patients. However, topical versions should be used in caution with patients prescribed warfarin as even rubbing it onto a small area of skin can increase the effect of warfarin which could lead to bleeds. Diclofenac is still considered to be safe for those without heart problems.

There was a similar warning a few years ago for another class of prescription only anti-inflammatory painkillers called COX-2 NSAIDs. COX-2 NSAIDs include brands like Celebrex^® and Arcoxia^®; these too must be avoided in people with heart problems.

 
Anti inflammatory painkillers that do not have a major cardiac warning (as of yet) include ibuprofen, meloxicam, naproxen and meloxicam. Hence doctors may consider prescribing these in cardiac patients where analgesia is required. Ibuprofen is available over the counter without prescriptions (eg. Nurofen^®) but I would not advise people with heart problems using Ibuprofen without first consulting with their pharmacist or doctor; this is because it can cause problems like raised blood pressure which can put pressure on the heart. Anti-inflammatory medicines must be used with care for other reasons too and should not be used long term (unless under supervision of your doctor). Apart from potential heart problems, they can cause stomach ulcers, trigger asthma attacks in asthmatics and should be avoided by those with kidney problems.

By Eamonn Brady MPSI

 *HSE Primary Care Reimbursement Service. Statistical Analysis of claims and payments 2010.

 
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